Faith, Health Care, and Dying – Some Points from a Buddhist Perspective
This is an article from Dayasara at Ipswich Buddhist Centre, looking at issues of health care and dying from a Buddhist perspective.

Geographical diversity of Buddhism
Sri Lanka, Thailand and Burma preserve the ancient Theravada form, with its characteristic yellow robed monks. The relatively later-developing Mahayana form(including Zen) is associated with Japan and China, Hong Kong, and Tibet. People from immigrant communities practising the religion of their country of origin may be very different from each other in style. There is a little bit of every part of world Buddhism somewhere in the UK.

Many people of ‘Western’ background are Buddhists
Many people have converted to Buddhism from a Christian, Jewish or other ‘western’ background. They are often followers of the more popular forms of Buddhism in the UK which have developed since 1950.

For Buddhists, the central purpose of life is to gain Enlightenment
Enlightenment is a state of being which has been discussed in terms of “pure, clear Awareness”, “intense, profound overflowing Love and Compassion” and “inexhaustible mental and spiritual Energy” (Sangharakshita 1990) . To achieve this Buddhists focus on what are known as the Three Jewels. These are the Buddha himself who lived and taught in Northern India/Nepal two and a half millennia ago and whose Enlightenment gives us an ideal of human development; the Dharma, which is his teaching; and the Sangha, which is the community of those who follow and practice the teaching. There are different schools of Buddhism.

Central teachings of Buddhism
All schools of Buddhism share comparable central teachings in relation to death, karma, and re-birth. We are seen as being on a ‘wheel’ of apparently endless re-births, a process which only the achievement of Enlightenment interrupts. Our actions resonate through these lifetimes, influencing them through the complex operation of karma. Mundane existence (or samsara) is characterised by features such as impermanence, unsatisfactoriness and insubstantiality. Craving prompts behaviour marked by greed, hatred and delusion, whilst through recourse to the 3 Jewels it is possible to cultivate qualities such as wisdom, compassion and clarity. Such ‘cultivation’ would comprise many possible practices. Meditations include the Mindfulness of Breathing to enhance calmness and concentration, and the Metta Bhavana, to help to develop loving kindness towards ourselves and all other beings, ultimately to the point where the self/other distinction breaks down.

The question of rebirth
Re-birth is crucial to Buddhist views of life and death (see Willson 1987 for a review). It is worth noting that many Buddhists prefer this term to that of ‘re-incarnation’, which tends to wrongly suggest a permanent, unchanging self which just keeps re-appearing in different physical guises. Equally Buddhists do not accept ‘nihilistic’ type views, such as that “there is this mundane life only”. One well-known metaphor for the relation between re-births is that of a flame being passed from one candle to another, with ‘something’ being transmitted onwards. Having said this, it may seem surprising that you do not have to believe in re-birth to be a Buddhist; I have heard that Sangharakshita (the founder of the Western Buddhist Order) has commented that it does mean that anyone in this situation has to gain Enlightenment in this lifetime, so there is no time to waste!

Things to do – not things to believe
Much of the Dharma(The teachings of the Buddha) is practical and pragmatic in nature, and one well-known Buddhist writer has suggested that Buddhism is as much concerned with things to do as with things to believe (see Batchelor 1997). An example of this from my own experience was that doing the Metta Bhavana meditation did seem to help me to become fully vegetarian. Perhaps all that is required in the early stages is a general interest in Buddhist teachings, and an openness to gaining greater awareness.

Between Death and Birth
What about death?. Classic Buddhist texts such as the Tibetan Book of the Dead (translated by Fremantle and Trungpa 1992) give an inspiring account of time spent in the bardo (or ‘in-between’) states, in which the recently deceased person dwells whilst awaiting re-birth; various factors may influence what happens next, including the influence of archetypal Buddhist figures. However, even for those with a strong background in Buddhism there will be variation as to how people apply these teachings to everyday life and death. The title of Sogyal Rinpoche’s (1992) book ‘The Tibetan Book of Living and Dying’ indicates his emphasis on the indivisibility of the two phenomena.

A human skull on the shrine
To a Tibetan Buddhist practitioner it is quite natural to keep a human skull on his/her shrine as a reminder of impermanence, and to meditate on the transitory nature of the body and our present existence.

To many in the West this would be considered ‘morbid’, and there is a usual pre-occupation with distracting activities and worldly ambitions. Green (1989) notes that a key factor is “the state of mind at the time of death, Buddhists believe that this will influence the character of re-birth”. This appears accurate, though ‘state of mind’ should not be interpreted too narrowly, as the person’s whole state of being will be of relevance. Ideally, there will be good support from those closest to the person; the Dharma places great importance on spiritual friendship as a practice, and clearly like-minded friends can help greatly at this time. The hospice movement has done much to improve the surroundings in which people die, and having a Buddhist shrine and other artefacts nearby may help to inspire the person and reflect beauty, truth and other positive human qualities.

Facing death free of unresolved issues
Buddhism has 5 basic Precepts, each indicating behaviour to avoid and a positive counterpart to cultivate.

We undertake not to kill or harm living beings, and also commit ourselves to develop metta or loving kindness(as mentioned above) towards all beings. With the second “taking the not given”, and makes the development of generosity its active/positive counterpart. Further precepts are concerned with sexual misconduct, truthful communication and the taking of intoxicants. Ethical behaviour is described as skilful, and will tend to lead to positive karma, with unskilful actions tending to produce the opposite. Different Buddhist traditions differ in their interpretations of Karma ‘“ some see all events that impact on one as being the effect of ones own actions at previous times, however we see this as a unnecessarily global ‘“ being struck by lightening would be due to an unwise decision to walk out in a thunderstorm not because of previous karma. Thus being involved in a disaster would not be our fault (unless we caused it!), and we would not feel responsible. The emotions we would feel would be our own spiritual responsibility.

What do Buddhists do without the comfort of an eternal heaven?
There is no God or eternal heaven in Buddhism. A Buddhist would not look at their own faith from this perspective ‘“ it is symptomatic of our overwhelmingly Christian or Abhrahamic cultural inheritance that we need to introduce Buddhism in these terms ‘“ Buddhists are as likely to say that there is no Buddha in Christianity, except that that is not true, the Buddha’s Enlightenment influenced the whole of Asia – the teachings of the Buddha have travelled to all the worlds faiths. There is no God in Buddhism, in the sense of a creator or universal judge; Sangharakshita (1994) has described karma in terms of a natural law, and likened in this respect it to the operation of gravity. Of course, when people are facing death they may feel the need to unburden themselves of past unskilfulness and to repair damaged relationships. There can also be the opportunity to rejoice in the good qualities of those who have been close to them, and reciprocation of such rejoicing will also often be of value.

When a Buddhist is approaching death their devotion to the Buddha and their faith in the Three Jewels would come to the fore, they might spend more time chanting devotional verses or mantras, and may wish their friends or family to practice with them, or read to them. The ear is said to be the last sense to go at death and reading inspirational texts is good practice to aid the death and re-birth process. There are heavenly realms in Buddhism where one can be reborn, some are described as ‘Pure Lands’ where Buddhas such as Amitabha preside, a particularly auspicious place to be reborn as all the conditions for swift progress towards enlightenment are present.

Conditions for a good death
A suitable care environment and empathic staff will naturally help create the conditions for a ‘good’ death (see also writers such as Levine 1986 on ‘conscious living and dying’). The Buddhist Hospice Trust newsletter contains useful material in this area.
To me, following a Buddhist path appears highly conducive to work in palliative care. It could be argued (a little provocatively!) that no-one should be allowed near vulnerable people without evidence of some effort to develop mindfulness, positive emotions, reflective self-awareness etc. We believe that meditation and other practices have great potential in this field.

Northcott (2002) makes some broadly useful points as to health care for Buddhists.

Sogyal Rinpoche (1992) seeks parallels between the influence of Buddhist and Christian figures at the time of death, whereas Buddhist teachers including Sangharakshita and Philip Kapleau note the differences between theistic and Dharmic world-views (see Rawlinson 1997).

Euthanasia
Revel and Ricard (1998) make some notable points about euthanasia, Sogyal Rinpoche (1992) gives more detail on bardo states and the ‘transference of consciousness’ (or phowa), and there is the question of volition in relation to re-birth.

I would recommend Christine Longaker’s (1997) book; she is a disciple of Sogyal Rinpoche and became involved in hospice care in the USA after the death of her husband. A useful general introduction to Buddhism, by a writer within the movement of which we are a part, is by Kulananda (1996).

Caution about post-mortems
Although Green (1989) states that generally Buddhists have “no objection to a post-mortem” , one Buddhist friend has commented to me on her view that bodies should not be disturbed in this way soon after death; there are beliefs that the consciousness may not have left the body immediately even if the person is ‘medically’ dead. So as with all people, individual preferences need to be talked about. This would be even more pertinent to organ donation as the organs are removed immediately ‘clinical’ death is ascertained by what medics call ‘the snatch squad’ at a point where Buddhists would consider that the spiritual process of death is still taking place.

Buddhist Funerals
Whilst the death process and the time shortly after death are sacred times for Buddhists, the disposal of the body is not, being more an opportunity for relatives and friends to take their leave. The body returns to the elements, heat dissipates, air is breathed out at the last breath, liquids return to the water element, and everything else returns to the earth element. Many Buddhists prefer cremation, on a pyre with the body visibly being consumed by the flames, the process being a vivid demonstration of impermanence.

Members of the Western Buddhist Order are available locally to conduct funerals – usually at the crematorium in this country, although woodland burials are becoming popular. Download a guide to Buddhist funerals here.

Buddhist Hospice Trust
For details of the Buddhist Hospice Trust and the Ananda Network (for Buddhist chaplaincy) contact Dennis Sibley on 01983-526945.

Disaster
A Buddhist would take responsibility for their own emotional and spiritual wellbeing ‘“ it is often noted that practicing Buddhists are unflappable, able to deal with difficulty with equanimity ‘“ this prepares them well to be altruistic at times of crisis as they will keep their cool and look to the needs of those around them. They would take comfort in their devotion to the Three Jewels, which provides a perspective on suffering, its cause, and the path to the cessation of suffering.

Disaster Plan
After the Tsunami disaster the Ipswich Buddhist Centre discussed forming a disaster plan. We created a file and asked for advice from a Sangha member who had been involved with creating civil disaster plans. He advised us and we have this advice in a file on the premises. The gist of the advice was that the best thing we could do was focus on being a place of worship ‘“ to open our doors for anyone who wanted to come in and meditate or perform Puja (religious worship).

We would welcome being part of a local plan for places of religious worship in the event of a local disaster.

We also created a Death file, with resources for funerals and ceremonies, so it is ready when needed.

References
BATCHELOR S (1997) Buddhism without Beliefs. London, Bloomsbury.
FREMANTLE F and TRUNGPA C (translators) (1992) The Tibetan Book of the Dead. Boston, Shambala
GREEN J (1989) Death with Dignity- Buddhism. Nursing Times Vol 85 No 9 1/3/89 pages 40-41.- some information may be out of date e.g. number of Buddhists in Britain, and also see citations of this article in main text above.
KULANANDA (1996) Principles of Buddhism. London, Thorson’s.
LEVINE S (1986) Who Dies? Bath, Gateway Books.
LONGAKER C (1997) Facing Death and Finding Hope. London, Century.
MIRAS D (2000) Dying by the Book. Raft (The Journal of the Buddhist Hospice Trust) No 18, Autumn 2000,pages 3-10.
NORTHCOTT N (2002) Nursing with dignity: Part 2- Buddhism. Nursing Times 7/3/02 Vol 98, No 10 pages 36-38.
RAWLINSON A (1997) The Book of Enlightened Masters. Chicago/La Salle, Open Court.
REVEL J-F and RICARD M (1999) The Monk and the Philosopher. London, Harper Collins.
SANGHARAKSHITA (1990) A Guide to the Buddhist Path. Windhorse Publications.
SANGHARAKSHITA (1994) Who is the Buddha? Windhorse Publications.
SOGYAL RINPOCHE (1992) The Tibetan Book of Living and Dying. London, Rider.
WILLSON M (1987) Rebirth and the Western Buddhist- 2nd edition. London, Wisdom Publications

The Authors
Dayasara (Martin Hillary) was ordained into the Western Buddhist Order in June 2001, and lives in a Buddhist residential community Maitriloka Community, Valley View, Hadleigh Rd, Ipswich IP2 0BT Phone 01473-252821

Jnanamitra(Nina Emmett) was Ordained into the Western Buddhist Order in May 1991 and lives in Ipswich, and was Chair of the Ipswich Buddhist Centre.